• Secondary goals: Softening of horizontal forehead wrinkling and vertical glabellar (the area between the brows) frown lines

• Anatomy:

Muscles of the Eyelid, Brow, and Face

A

Orbicularis Muscle (palpebral)

Eyelid closing muscle

B

Orbicularis Muscle (orbital)

Eyelid closing muscle

C

Frontalis Muscle

Forehead muscle

D

Procerus Muscle

Muscle that lowers brows

E

Corrugator Muscle

Muscle that brings brows together

F

Midfacial Muscles

Muscles of the cheek

G

Malar Fat Pad

Large cheek fat pad

H

Suborbicularis Fat (SOOF)

Fat pad beneath orbicularis muscle

I

Temporalis Muscle & Fascia

Muscle of temple

• Anesthesia: Different surgical options are availabl; the more extensive the approach, the deeper the level of required anesthesia. General anesthesia or deep intravenous sedation ("twilight sleep") is advisable for coronal forehead lifts.

• Operative technique: Many operations and combinations of operations exist, so the actual lift may be achieved by of skin and muscle removal, tucking of underlying muscle, and/or loosening of forehead and scalp periosteum with physical resuspension at a higher level. Incisions may be closed by using simple sutures, staples, bone screws, or sutures placed through bone tunnels.

• Coronal forehead lift (also called open, transcoronal, or bi-coronal brow lift), in which the scalp is incised from ear to ear over the top of the head. The incision is usually hidden about an inch into the hair but may sometimes be placed just in front of the hairline (pre-trichial incision) if the hairline is already relatively high.

• Endoscopic forehead lift, in which the forehead is loosened and elevated through three or four one-inch long incisions hidden in the scalp using specialized instruments and a small camera called an "endoscope"

• Temporal lift, in which the incision is made over the temple and only the outer portion of the brow is lifted

• Midforehead lift, in which the incision is placed within a deep wrinkle on the middle of the forehead

• Direct brow lift, in which an incision is made just above the eyebrow hair, after which a strip of skin and muscle excised. The deeper tissues are then supported as in browpexy. Although this operation can yield a vigorous lift, its main disadvantage is the creation of a noticeable external scar that is slow to fade, and so it is seldom used for cosmetic purposes.

• Internal brow lift, in which the brow is stabilized through the open upper blepharoplasty incision by releasing its check ligament and muscular depressors, thus allowing it to elevate naturally under its own power or be elevated with sutures (browpexy). The sub-brow fat pad (ROOF) is sometimes thinned slightly (browplasty).

• Endodtine "transbleph" brow lift, a variation on the internal brow lift in which a soft plastic-like hooked implant attached to a tiny drill hole in the bone rather than internal sutures is used to reposition the brow tissue. The implant is biodegradable and eventually reabsorbs after healing.

• Non-incisional RF heating, in which radiofrequency energy applied to the skin of the forehead and temple supposedly tighten the deeper tissues

• Cable brow lift, in which thick suture placed deep below the skin mechanically connects the eyebrow to tissues below the scalp to create a suspension.

• Botox brow lift, an injectable rather than surgical procedure, is covered here.

• Limitations: For endoscopic brow lifting, the ideal candidate is a woman with thick hair, a low hairline, normal or thin skin, and slight brow droop; patients with thicker skin or more advanced drooping are generally better served with a full coronal forehead lift. Radiofrequency and cable brow lifts are relatively new and associated with high failure rates. Severe brow descent is difficult to address successfully with any procedure other than a direct brow lift.

Contrary to the proclamations of some enthusiatic surgeons, brow or forehead lift (in reality, an upper face lift) does not substitute for a blepharoplasty, even though it can pull excessive skin upward. Each operation is directed at a different problem and achieves a different effect. When indicated by the patient's condition, the two procedures may sometimes be performed simultaneously. Unless there is clear evidence that the forehead has actually drooped, however, conservatism is wise.

• Care and recovery: Bruising, swelling, and pain are more pronounced than with blepharoplasty, especially with the more invasive variations of the operation. Recovery is usually rapid, especially with endoscopic-assisted surgery skillfully performed.

• Risks and complications: Aside from aesthetic concerns from overpullling or shape distortions, the most common complication is objectionable scarring. When surgery is performed from within the hairline, the scars are hidden but may still become depressed or be associated with hair loss. When the incisions are made in visible skin, the scars are noticeable, slow to fade, and not always well hidden by natural creases. Smokers are prone to poor healing. Only the internal brow lift (browplasty, browpexy, endotine) creates no additional scar (but is a weaker procedure that works only on the lateral brow and doesn't hold up well over time).

Other less common complications include nerve damage, hematoma (large blood clot), asymmetry, excessive bruising and swelling, numbness, and scalp itching. When combined with simultaneous upper eyelid blepharoplasty, the risk of lagophthalmos (inability to close the eyes fully) is increased.

Contrary to popular opinion, a recent survey conducted by the American Society of Plastic Surgeons found that the complication rates of the open coronal method and closed endoscopic method were comparable, while the coronal lift method was generally believed to be more efficacious and long-lasting.

While some enthusiastic surgeons may suggest that complications from brow lift are "exceedingly rare," one needs only to view the results in many high profile celebrities to feel otherwise.

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